Posttraumatic stress disorder, depressive and cardiovascular disease symptoms among young patients receiving medical treatment in a heart centre: A cross-sectional study

Abstract Introduction: Exploring the connections between traumatic experiences and subsequent health outcomes is vital for informing clinical practices and public health policies. The study aimed to investigate the relationship between lifetime trauma exposure and posttraumatic stress disorder (PTSD), depressive and cardiovascular disease (CVD) symptoms. Methods: A total of 171 patients who received treatment in a local heart centre were included in this study. Several questionnaires such as the Life Event Checklist-5, Posttraumatic Stress Disorder Checklist for DSM-5 and Patient Health Questionnaire-9 were used to measure their traumatic experiences and PTSD and depressive symptoms, respectively. Physiological measures were also examined. Data were analysed using SPSS. Results: The chi-square test showed significant differences in the percentage of reported PTSD symptoms among the patients with CVD (24.0%), patients with kidney disease (4.3%) and patients with other health problems (7.1%). The patients with CVD reported having a significantly higher percentage of PTSD and depressive symptoms than the patients with other medical conditions. The patients with CVD who reported having PTSD symptoms had significant systolic blood pressure (SBP) and heart rate changes compared to the patients who did not. The patients who reported PTSD symptoms had a significantly shorter sleep duration than their counterparts. The SBP and diastolic blood pressure differed significantly between the patients with and without PTSD symptoms. Conclusion: Earlier detection, prevention and intervention related to trauma exposure and PTSD symptoms are suggested to reduce the CVD risk.


Introduction
In Malaysia, cardiovascular and pulmonary diseases represented 7738 admissions or 16.09% of the total mortality in 2009, 1 increasing to 28.1% in 2012. 2 e Malaysia National Strategic Plan for Non-Communicable Disease 3 lists stress as a cardiovascular disease (CVD) risk factor.Adverse childhood experiences intensify posttraumatic stress disorder (PTSD) symptoms in adulthood,4,5 a psychiatric disorder resulting from life-threatening trauma.PTSD includes symptoms like anxiety, hopelessness with a negative worldview and avoidant behaviours. 4,5[6] Individuals with trauma exposure accompanied by chronic stress and PTSD often exhibit prolonged unhealthy stress responses. 7][6] Increased trauma exposure and/or PTSD have more adverse cardiovascular-related outcomes and higher CVD-related mortality rates. 5,6accarino et al. 8 highlighted a strong association between PTSD and coronary heart disease.ey found that twins with PTSD showed a higher incidence of coronary heart disease (90%) and a more compromised myocardial perfusion than twins without PTSD even after counting for established heart disease risk factors.
ey concluded that shared environmental and genetic factors do not fully explain this association. 8Among military personnel and veterans, 8.3% experience illness-induced PTSD, particularly in conjunction with heart disease and the presence of stroke doubles the prevalence of non-life-threatening physical health conditions. 9onsistent with the bidirectional association between CVD and PTSD, literature suggests a similar association with depression.Depression is more prevalent among patients with CVD patients than the general population, leading to higher mortality rates and poorer health outcomes. 10,11However, most previous studies have focused on middle-aged populations.
Traumatic exposure and PTSD negatively impact mental and physical health.However, previous studies often focus on men or military veterans with disproportionately high rates of obesity, diabetes, hypertension, psychological disorders and CVD, limiting generalizability.][10] Young patients undergoing medical treatment, particularly for chronic conditions like CVD, face unique challenges compared to older adults. 5,6ir developmental stage and the long-term impact of medical interventions may heighten susceptibility to trauma and stress a ecting cardiovascular health.Investigating the association between PTSD and CVD in this population is critical for early risk identi cation and preventive measures.However, literature gaps persist in understanding trauma exposure and PTSD among young CVD patients.Our study aimed to establish this association, hypothesizing that a high prevalence of PTSD symptoms and signi cant physiological di erences between traumatised and nontraumatised young CVD patients.is endeavour is crucial for informing e ective prevention and treatment strategies.

Methods
Participants A total of 171 patients were recruited from Sarawak General Hospital Heart Centre with a mean age of 30.1 years (Standard Deviation(SD)=11.24) and 52% were men.Seventy-ve (43.9%) patients received an o cial CVD diagnosis.Individuals who registered in local heart centre, were aged 18-40 years and were willing to participate in the study were included.ey were randomly selected from the registration les.Conversely, patients who were at high risk or undergoing surgery on the same day of data collection were excluded.

Measures
Demographic variables including age, sex and ethnicity were collected.
Trauma exposure e participants were instructed to complete the Life Event Checklist-5 (LEC-5), 12 which contains 17 items on traumatic and negative life events.Each question asks whether individuals have either direct or indirect exposure to the listed potentially traumatic events.In this study, ve items derived from the literature review and pilot study were added to the original 17 items including near drowning, robbery, parental separation, persecution/humiliation and childhood neglect.
e Cronbach's alpha value of the LEC-5 was 0.73.

PTSD
e Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) 13 is a self-administered questionnaire with 20 items corresponding to the DSM-5 PTSD symptoms.Generally, individuals respond to each item on a 5-point Likert scale to re ect the level of distress associated with each symptom, generating a total score ranging from 0 to 80.A cut-o of 33 is utilised to determine the absence and presence of PTSD. 14In the present study, the PCL-5 showed good internal consistency (α=0.91).

Depression
e Patient Health Questionnaire-9 (PHQ-9) 15 is a nine-item self-report questionnaire used to detect the presence of depressive symptoms in the past seven days.Each item is scored on a 4-point scale, yielding a total score ranging from 0 to 27.A total score of 0-4 is interpreted as no depressive symptoms, 5-9 as mild depression, 10-14 as moderate depression, 15-19 as moderately severe depression and ≥20 as severe depression.
e Malay-version PHQ-9 was validated in a Malaysian primary care clinic. 16e Cronbach's alpha value of the PHQ-9 was 0.81.

CVD and other physical health problems
e medical records of the participants were checked to obtain their health status.

Smoking, alcohol drinking and sleeping duration
An adapted US National Health Interview Survey Checklist 17 was used among the participants who had ever engaged in healthrelated behaviours (e.g.cigarette smoking, alcohol drinking and sleeping duration) and experienced a series of symptom-based conditions (e.g.chronic headache and chronic low back pain).Smoking intensity was categorized as 0 (never smoked), 1 (1-10 cigarettes/day), 2 (11-20 cigarettes/day), 3 (>20 cigarettes/day), or 4 (former smoker).Heavy alcohol use was de ned as consuming ve or more drinks (>3000 mL for 2%-5% alcohol) on ve or more occasions weekly over the past 30 days.Moderate drinking included one drink per day for women and two for men.Participants also reported their nightly sleep duration.

Physical activities
e participants were asked about the frequency and intensity of their physical activity in a week.
e agreement between self-reported and physician-diagnosed health issues and physical activities was strong, resulting in limited bias for research purposes in studying the association between mental and physical health. 18For the full study sample, the Cronbach's alpha value of the adapted US National Health Interview Survey Checklist in the present study was 0.72.

Body mass index (BMI)
BMI was measured using the participant's height and weight via a stadiometer and weighing scale available at the hospital.It is calculated as kilograms per square metre.A BMI of 25.0-29.9kg/m 2 indicates overweight; ≥30 kg/m 2 , obesity; <18.5 kg/m 2 , underweight; and 18.5-24.9kg/m 2 , normal weight.

Physiological measures
Blood pressure was measured using a blood pressure machine provided by the hospital at three time points: before participants completed questionnaires (T1), when the participants completed traumatic events and PCL-5 questionnaires (T2), and after completing all questionnaires (T3).Participants were informed on avoiding blood pressure changes during questionnaire completion.

Data collection
Patients aged 18-45 years were randomly selected from registration les after obtaining consent from doctors or nurses and participants.All participants provided signed consent and were informed about their rights, potential risks and con dentiality.Procedures and timing of measuring their physiological responses were explained.Demographic information was voluntarily completed by all participants.Participants completed the questionnaires on their traumatic history, mental and physical health history, substance use habits (i.e.alcohol drinking, cigarette smoking), sleeping duration, and physical activities.

Translation
For this study, all instruments were translated into the Malay language (Bahasa Malaysia) and were back-translated by two academicians who were experts in both English and Malay languages.e content validity and reliability of the translated versions were evaluated and tested in a pilot study.

Data analysis
Descriptive statistics (frequencies, percentages) were used to present variables including trauma exposure prevalence, the time interval between trauma and assessment, health symptoms, PTSD scores, and BMI.Di erences in the physiological measures (blood pressure, heart rate (HR), BMI) and unhealthy behaviours between the participants with and without traumatic experience and PTSD symptoms were evaluated using independent t-test for continuous variables and Pearson chi-square test for dichotomous variables.A P-value of <0.05 was considered signi cant.

Results
Descriptive analysis of trauma exposure and PTSD symptoms Approximately 83.6% (n=143) of the participants reported at least one exposure to trauma, while 25.7% exhibited PTSD symptoms.
e participants with PTSD symptoms also had greater HR changes (M=7.34,SD=12.69)than those without.e participants without PTSD symptoms had smaller HR changes (M=3.0,SD=10.32)than their counterparts.ere was a signi cant di erence in the reported sleeping duration [t (167) =2.43,P=0.016](Table 5).e participants who reported PTSD symptoms had a shorter sleeping duration (M=6.43,SD=2.02)than those who did not (M=7.17,SD=1.62).ere was no signi cant di erence in the health behaviours or other measures including physical activities, drinking, smoking, BMI between the participants with and without PTSD symptoms.Similar results were found in all physiological measures between the participants with and without depressive symptoms.
PTSD symptoms and trauma exposure were associated with physical health problems.
e ANOVA showed a signi cant relationship between the number of trauma exposures and the number of physical health problems reported [F (15,116)

PTSD symptoms in relation to physiological measures
e repeated-measure ANOVA revealed that the mean SBP signi cantly di ered between the participants with and without PTSD symptoms across the three time points (1.85,303.23)=25.71,P<0.001](Table 6).Posthoc pairwise comparison with Bonferroni correction showed that the SBP signi cantly increased from T1 to T2 (mean score=120.43vs 131.86) and signi cantly dropped at T3 (mean score=121.8,P<0.001).However, the increase in the SBP was not signi cant from T1 to T3 (mean score=120.43vs 121.8,P=0.18).ese results indicated a signi cant time e ect on PTSD symptoms based on the SBP.e repeated-measure ANOVA showed that the mean diastolic blood pressure (DBP) signi cantly di ered across the three time points [F (1.96,320.67)=4.27,P=0.015](Table 6).Post hoc pairwise comparison with Bonferroni correction demonstrated that the DBP signi cantly increased from T1 to T2 (mean score=76.84vs 79.43,P=0.031).However, the di erence in the DBP between T2 and T3 did not reach signi cance (79.43 vs 77.24,P=0.081).e DBP change across the di erent time points between the participants with and without PTSD symptoms also did not reach signi cance [F (1.96,320.67)=0.86,P=0.422].
ese results indicated a signi cant time e ect on the DBP.e repeated-measure ANOVA demonstrated that the mean HR di ered signi cantly across the three time points [F (1.96,320.75)=21.03,P<0.001](Table 6).Post hoc pairwise comparison with Bonferroni correction showed that the HR signi cantly increased from T1 to T2 (mean score=88.40vs 92.27,P<0.001).However, the di erence in the HR between T2 and T3 did not reach signi cance (92.27 vs 88.08,P=1.00).e HR change across the di erent time points between the participants with and without PTSD symptoms also did not reach signi cance [F (1.96,320.75)=3.00,P=0.052].ese results revealed a signi cant time e ect on HR.

Discussion
e present study investigated the association between trauma exposure and/or PTSD and CVD.
e prevalence of PTSD symptoms among the clinical sample was 25.7%.Substantial research has revealed signi cant incidents of PTSD caused by CVD in the past 20 years. 9,19is study proposed that patients with illness-induced PTSD have a higher prevalence of persistent/recurrent PTSD and a lower prevalence of remitted PTSD.
In this study, PTSD symptoms were signi cantly associated with elevated SBP across the di erent time points, suggesting sensitivity to homeostatic regulation, possibly explained by the polyvagal theory. 20s theory posits that PTSD symptoms have biological underpinnings and can manifest somatically.It suggests that the ventral vagal complex, part of the parasympathetic nervous system and known as the 'social nervous system' plays a crucial role.During safe conditions, it promotes rest, but during threats like trauma, it activates the sympathetic nervous system's ght-or-ight response.
In most traumatising situations, when individuals cannot resolve threats through ghtor-ight responses, they activate an evolutionarily older, unmyelinated part of the vagus nerve to survive, leading to a shut-down condition and dysregulated physiological responses. 20s aligns with ndings from a study on biomarkers for PTSD onset and maintenance, highlighting SBP as a consistent biomarker across 1-, 4-, and 12-month follow-ups post-trauma.21Understanding PTSD's aetiology is crucial for explaining the mechanism of the association between PTSD and CVD.In our sample, PTSD symptoms were shown to a ect SBP, suggesting this impact may manifest early in young adults.
Similar ndings were noted by Stein et al. 22 based on data from 10 countries (N=18,630), who reported hypertension starting as early as age 21 years in individuals with two or more childhood adversities, despite their majority being aged 45 years and older. 23association of adverse life experiences, PTSD, and unhealthy behaviours aligns with the allostatic load theory.24 is theory posits that extreme stress triggers physiological responses such as increased heart rate, blood pressure, blood sugar levels, arteries constriction, and immune suppression.Subsequently, these responses can lead to stickier platelets, arterial wall damage, and weakened heart muscle, 24 possibly explaining the elevated blood pressure and HR observed among the traumatized individuals in our study.
Physiological responses to stress are mediated by amygdala activation. 25Tawakol et al. 25 examined both the physical and biochemical impacts of stress, supporting the allostatic load theory and its association with cardiovascular events.e elevated SBP observed in young patients in our study further supports the idea that elevated blood pressure not only poses a risk for CVD but may also in uence PTSD onset and overall physical health.Our ndings suggest that CVD rather than kidney disease, may have a stronger association with PTSD onset.Practitioners and researchers may fail to recognise a signi cant life-threatening disease as traumatic, misidentifying patients experiencing illnessinduced PTSD. 7As a result, regardless of DSM-5 classi cation, practitioners should remain vigilant in diagnosing PTSD in patients with lifethreatening diseases, ensuring timely recognition and support.
Trauma-focused interventions are crucial for enhancing public health e orts in preventing and detecting CVD early.Professionals including paediatricians, child psychologists, social workers and educators need to recognize the sequelae of traumatic exposure in children and adolescents.Prevention strategies, such as regular monitoring and early interventions, should be prioritized for children and adolescents exposed to traumatic events.

Limitations and strengths
e reliance on retrospective reporting of lifetime trauma is one of the study's limitations; the number of lifetime traumas may be underreported or change over time.An assessment of the validity of adult retrospective accounts of unpleasant childhood events revealed that while the retrospective study may have a bias, it is not su ciently signi cant to invalidate retrospective research. 26present study did not investigate the biochemical consequences of trauma exposure and PTSD on CVD.Dysregulation of proin ammatory and anti-in ammatory cytokines due to stress may disrupt immune balance, potentially contributing to CVD development in trauma-exposed or PTSD-a ected individuals.24,27 Future research should explore these biochemical mechanisms further, as this was beyond our study's scope.Assessing blood pressure remains a quick and e ective method to predict future cardiovascular events, 28 with our study demonstrating a link between elevated blood pressure and chronic stress.
Future studies should consider incorporating additional psychological measures such as anxiety level.Notably, DSM-5 reclassi ed PTSD under trauma and stress-related disorder rather than anxiety disorder, 7 the relationship between anxiety disorder and CVD risk remains less understood compared to trauma and depression.A 2010 meta-analysis of 20 studies discovered that individuals with premorbid anxiety faced higher risks of incident CVD and cardiac death among community samples and veterans over 37 years of follow-up. 27-30However, previous studies often did not adjust for depression, leading to mixed ndings regarding the association between anxiety and depression. 30spite its limitations, the current study highlights several strengths.It examines the association between PTSD with CVD in comparison with depression and other physical health problems like kidney disease, suggesting that speci c physical conditions, like CVD, can trigger illness-induced PTSD.Given the high comorbidity of PTSD, anxiety and depression distinguishing psychological symptoms solely due to life-threatening physical conditions is challenging. 30s often results in underrecognition and inadequate treatment of illnessinduced PTSD compared to traditional PTSD, potentially leading to more chronic or complex CVD.
Unlike studies focusing on a speci c traumatic event, our study utilized a comprehensive range of traumatic events to demonstrate their signi cant impact on CVD through PTSD. is approach di ers from previous studies limited to speci c traumatic events and populations (e.g., veterans, physical or sexual abuse, women), limiting generalizability. 9,19,21Including various traumatic events enabled a robust comparison of their association strength with PTSD and CVD in our clinical sample.Moreover, our study extended existing literature by assessing blood pressure and HR during and after testing, facilitating temporal comparisons of traumatic memories with physical conditions.

Conclusion
is study explored the enduring psychological and physical sequelae of trauma and PTSD, employing the polyvagal theory to elucidate their association with CVD.Elevated blood pressure and HR were signi cantly associated with trauma exposure and PTSD, while unhealthy behaviours were associated with certain traumatic events.Although causality was not established, PTSD mediated traditional CVD risk factors.Traumatic events likely in uence biological processes, leading to adverse health outcomes in adulthood.
e study underscores the importance of early detection of physiological measures in traumatized young adults, advocating their inclusion in health promotion and prevention programs to mitigate CVD risk.Screening for trauma exposure and PTSD symptoms in primary healthcare settings could enhance mental well-being and signi cantly reduce the burden of CVD, particularly among adolescents and young adults.

How does this paper make a di erence in general practice?
• is study highlights the complex relationship between trauma exposure, PTSD symptoms, elevated blood pressure and heart rate and unhealthy behaviours.Understanding this association is crucial for screening and early intervention.
• Recognising the abovementioned association can allow general practitioners to provide more holistic care to enhance patients' overall well-being.• Given that unhealthy behaviours are associated with speci c traumatic events, treatment plans must be tailored.• e ndings can inform public health initiatives aimed at preventing and addressing the consequences of trauma.In particular, public health programmes can be designed to target at-risk populations e ectively.

Open Access:
This is an Open Access article licensed under the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original author(s) and source are properly cited.See: http:// creativecommons.org/licenses/by/4.0/

Table 1
presents participants' detailed demographic characteristics.
** Duration of traumatic experience = year of study administration − year of trauma exposure.

Table 5 .
Patients with cardiovascular disease with and without PTSD symptoms in reporting physiological changes (N=171).

Table 6 .
Repeated measure for PTSD symptoms in relations to physiological measure across three time (N=171).